Looking for inspiration in the New Year? Take a closer look at these eight easy-to-implement ideas from your peers that your hospital can use to drive results into the future.
By Megan McDonnell Busenbark
Illustrations by Joe Moccia
Take fewer chest X-rays
Children's National Health System in Washington, D.C., is reducing unnecessary chest X-rays in its NICU, and improving outcomes while driving down costs. With guidance from the American Academy of Pediatrics, Children's National decreased the frequency of chest X-rays used to verify positioning of a child's ventilator tube from daily to just twice a week.
Idea No. 1 Results
After implementing the program:
- Accidental extubations dropped from 1.18 events per 100 ventilator days to 0.41 events per 100 ventilator days—a 65 percent decrease within five months
- The NICU's monthly X-ray expenditure decreased to $159,424—nearly $1.6 million in annual savings
Fewer X-rays means a lower likelihood of an accidental extubation—an event that can cause serious harm and, on average, nearly doubles the length of stay compared to that of a newborn whose breathing tube remains in its proper place.
Fewer X-rays also means less exposure to radiation. To ensure the team caused no harm, the rate of unintended extubations and concerns from the clinical team were monitored. For Michelande Ridoré, M.S., the program lead in Children's National's Division of Neonatology, the benefit is clear. "This strategy is life-saving," Ridoré says. "We're reducing a burden on a child and a potentially worse outcome if the tube had been dislodged." Children's hospitals can replicate this strategy simply by cutting back on the number of these chest X-rays in accordance with Children's National's protocol.
Game on: Engage patients and improve care
Sometimes inspiration for great ideas comes from outside the hospital industry. For four years in a row, Union Pediatrics, a private pediatric practice in Union, Kentucky, has posted the highest scores nationally for well-child exams and overall clinic score among peer facilities on its electronic health record platform.
Idea No. 2 Results
Since the program started in 2014:
- The percentage of scheduled appointments rose from 17 percent to 62 percent in 2017
- Well-child visits for teens increased from 85 percent to 95 percent—above the national average of 56 percent
- Streamlining efforts resulted in fewer reminder phone calls or postcards
The secret? Gamification. Looking to boost patient compliance with appointments, vaccinations and healthy behaviors, Robin Warner, M.D., FAAP, added a gaming component. Using an app, patients or their caregivers earned points on their "loyalty card" for behaviors Warner assigned.
In addition to keeping up with appointments, Warner incentivized preventive health activities—patients uploaded data from Fitbits or entered diet and exercise information into Union Pediatrics; patient portal to earn points. Points could be redeemed for entries into gift card drawings.
The lure of prizes may have motivated some, but for many, it was the thrill of the game that enticed them. "It was a victory for them to fill up their card," Warner says. "It became a challenge, and they felt rewarded to get all the points." The program was so successful that Union Pediatrics has replaced it with a social media page focused on healthy lifestyles. Warner says the habits are now ingrained in her patients.
The key is to look at what metrics you want to improve: Attendance at follow-up visits? Adherence to medication schedules? Commitment to healthy behaviors? Also, sell your staff on the program—this will make the roll out more successful. Appropriately challenge your patients. Don't make goals too easy or too hard.
Group neonates with similar conditions
When Prabhu Parimi, M.D., joined Johns Hopkins All Children's Hospital in St. Petersburg, Florida, two years ago, he found a care model that didn't fit his vision for optimal, patient outcomes, including a continuum of care from pre-birth through early childhood. "What I saw was that despite the babies being in one unit, care seemed fragmented," says Parimi, director of its Maternal, Fetal & Neonatal Institute and Neonatology Division chief. "It struck me that grouping them together was the best way to address this problem."
Idea No. 3 Results
Using the grouping model for babies with NAS, the hospital had:
- A 41 percent reduction in the use of pharmacotherapy
- An increase in the use of mother;s milk in the eligible population, from 69 percent to 100 percentt
- A reduction in average length of stay from 16 days to nine days
Over the last year, the first phase of this plan took shape with a focus on a Neonatal Abstinence Syndrome (NAS) cohort. NAS babies were located together in one area of the NICU, along with a dedicated team of clinical experts specific to the needs of this patient population. Additionally, a team of NAS-specific providers was assembled to perform a dedicated rounding process for the NAS group.
The biggest investment children's hospitals need to make to replicate this approach is time, Parimi says. Still, it only took a matter of months for the team at All Children's to fully implement this new strategy—from the new co-location and staffing model to getting all of the team members in sync. In addition to the measurable benefits, Parimi says this drives an important culture shift. "Establishing a cooperative effort across the care providers is the most important part of it," Parimi says. "Caring for patients this way will change the physician culture toward one of collaboration and relationship building."
Keep parents in the know
Children's hospitals are finding new ways to keep families informed when their children are rushed away to receive critical care. Using Snapchat-like, HIPAA-compliant apps, Nationwide Children's Hospital in Columbus, Ohio; Arnold Palmer Hospital for Children in Orlando; and St. Louis Children's Hospital are among those using technology to keep families up to date while they wait for their child to come out of surgery.
Idea No. 4 Results
Children's Hospital of Pittsburgh at UPMC had more than 114,000 Snapchat views in 2017. A team uses it to share behind-the-scenes looks at the hospital and access to special events.
Hospitals are sharing secure, real-time communications from the operating room with anxious parents in the waiting room. They are also using Snapchat to engage patients and families in the community. As a messaging platform and social network, Snapchat lets users "chat" with friends by sending photos or videos. One distinguishing factor of Snapchat is the fleeting nature of all content shared on the platform. Photos and videos essentially disappear a few seconds after they've been viewed.
"Snapchat is visual storytelling, and it's what our patients are using," says Andrea Kunicky, media relations manager at Children's Hospital of Pittsburgh of UPMC. "It's a way to promote a brand and increase engagement with the target audience—patients and families." Snapchat has nearly 200 million active users sharing 3 billion interactions per day and is the most popular social media app among teens and millennials.
Hand washing compliance
To fight infection, Nationwide Children's Hospital in Columbus, Ohio, went the military route. When the hospital experienced an uptick in hospital-acquired infections in 2009, it cracked down on hand hygiene. Despite high self-reported rates of proper hand washing, undercover monitors showed actual rates closer to 60 percent. "We wanted to make a statement," says Terry Davis, M.D., assistant to the chief medical officer at Nationwide Children's. "The idea of the stand-down came up." A practice borrowed from the military, the hospital's stand-down began with a safety summit.
Idea No. 5 Results
Within a few months of the stand-down:
- Handwashing rates exceeded 90 percent and have remained at that level
- Hospital-acquired infections decreased
All staff members attended a mandatory meeting on hand washing safety, and leaders were tasked with making plans for their departments. A week later, the stand-down took place. All non-essential hospital activity ceased for 15 minutes, and department heads laid out plans to get their teams to 90 percent compliance within two weeks. If a department failed to meet that threshold, or if an individual was not complying, he or she would meet with the chief medical officer or chief nursing officer to explain why.
Davis attributes the sustained hand hygiene rates to a culture change prompted by the stand-down. For an effort like this to be successful at your hospital, share a story of patient harm to demonstrate the need for change—Davis calls this a burning platform. Sell staff on why it is necessary, and secure buy-in from senior management.
Mental health: Use art therapy
Art therapy is a form of expressive therapy that uses the creative process to improve a person;s physical, mental and emotional well-being. But this is not just arts and crafts time. For starters, art therapists are trained in art and therapy and hold advanced degrees and board certification.
Idea No. 6 Results
One adolescent recovering from an eating disorder at Children's Colorado says, "I believe that art saved my life, or at least my soul. In art, I find a safe place to be my true self."
Art therapy can get kids to open up in ways that traditional therapy can't. Not only do kids express themselves more freely, but even subtle cues—such as their choice of media, from pencils to paint and beyond—give the art therapist insight into what a child is feeling, according to Tisha Adams, Ed.D, LPC, art therapist in Children's Hospital Colorado's Ponzio Creative Arts Therapy Program.
Beyond its applications in mental health care, art therapists see effects on children with physical ailments. "I can't tell you how many times I've had parents in the hospital room tell me, 'That's the first time I've seen my child smile in a week,'" says Tony Edelblute, LPC, MT-BC, a music therapist in the Ponzio Creative Arts Therapy Program. "It's more profound than just distraction."
Art therapy is gaining acceptance as more children's hospitals add programs to complement traditional care. "We're not going to replace surgeons or amazing medical advancements," Edelblute says. "But we're addressing a dimension of wellness that doesn't necessarily get touched by surgery or medicine."
To get started, tap your interns, says Edelblute, who began his career at Colorado Children's as an unpaid intern. This demonstrates the value art therapy can bring before investing in staff and supplies to expand to a full-fledged art therapy program.
Patient sleep: Focus on simple fixes
The (necessary) bells and whistles in NICUs and PICUs have long made sleep elusive in the hospital setting. While no one would refute the need for and benefits of sleep for patients, the need to care for these patients often trumps their ability to get proper rest. Robyn Stremler, RN, Ph.D., adjunct scientist with The Hospital for Sick Children in Toronto, co-authored a study showing hospitalized children get significantly less sleep than recommended for their age—as many as two hours less per night.
Idea No. 7 Results
Hospitals can make strides to improve patient sleep. Stremler cites a study by Efrosini Papaconstantinou, Ph.D., at the University of Toronto, where teaching pediatric patients deep breathing and relaxation techniques resulted in 50 minutes more sleep per night than patients who didn't use the techniques.
That sleep is also interrupted more than a dozen times a night on average in the hospital. "It's a double-edged sword," Stremler says. "They're not getting enough minutes of sleep, but it's also broken-up sleep." And it's not just the kids who aren't getting sufficient shut-eye.
Another study showed more than a quarter of the nights parents spent with their hospitalized children met criteria for acute sleep deprivation. But children's hospital teams and other experts are focused on finding simple ways to create an environment and an opportunity for pediatric patients to get better sleep without sacrificing quality of care. Here's how:
- Cluster vitals, blood draws and medications for fewer interruptions
- Assess and decrease the frequency of vitals and check-ins based on patient severity
- Establish quiet hours with dim lights and reduced noise levels
- Shift tasks, such as bathing, to hours best suited for children, not necessarily staff members; convenience
- Coordinate floor cleaning and trash removal during daytime hours
- Provide access to quiet, comfortable sleep locations for parents
Change the way teams communicate
Shortcomings in provider communications on patient handoffs are a leading cause of preventable errors in hospitals. Enter I-PASS. The mission of the I-PASS Study Group: to improve patient safety by standardizing provider communication, with a specific focus on improving transitions of care. I-PASS is an evidence-based, standardized approach to teaching, evaluating and improving handoffs.
Idea No. 8 Results
I-PASS was tested in nine centers over a three-year period and drove significant results:
- Medical errors decreased by 23 percent
- Preventable adverse events decreased by 30 percent
- Improved written documentation and verbal communication
- No significant changes in the duration of the verbal handoff per patient or resident workflow
More than 50 medical faculty members from institutions across North America contributed to the curriculum, and its name is a mnemonic for the key elements of the handoff process. The mnemonic is integrated throughout the I-PASS curriculum and serves as the framework upon which the process is taught. "It's a simple structure," says Amy Starmer, M.D., M.P.H., the director of primary care quality improvement at Boston Children's Hospital and the I-PASS Study project leader.
"But what makes I-Pass one-of-a-kind is we pair it with other implementation strategies to change provider behavior and transform the way people are communicating." Children's hospitals looking to improve patient safety by standardizing provider communication around patient handoffs can learn about the participating children's hospitals and start with a free download of the I-PASS curriculum materials. The I-PASS Study Group also offers a consultation program to help hospitals with implementation.
Plus: 3 more ideas to "borrow"
Still looking for more inspiration to kick-start the year? Here are some quality and safety success stories that are adaptable for your hospital.
What strategies or ideas is your hospital implementing in 2018? Share your story.